Dysphagia Flashcards
Dysphagia is
difficulty in swallowing
usually associated with a sensation of holdup of the swallowed bolus ± pain.
Its origin is either:
- Oropharyngeal, mainly
* neuromuscular, e.g. CVA - Oesophageal, mainly
- achalasia
- diffuse spasm
- peptic structure often secondary to reflux
Probability diagnosis
Functional (e.g. ‘express’ swallowing, psychogenic)
Tablet-induced irritation
Pharyngotonsillitis
GORD/reflux oesophagitis
Serious disorders not to be missed
Neoplasia/cancer:
- cancer of the pharynx, oesophagus (esp.) stomach
- extrinsic tumour
AIDS (opportunistic oesophageal infection)
Stricture, usually benign peptic stricture
Scleroderma
Neurological causes:
- pseudobulbar palsy
- multiple sclerosis
- motor neurone disease (amyotrophic sclerosis)
- Parkinson disease
Pitfalls (often missed)
- Foreign body
- Drugs (e.g. phenothiazines)
- Subacute thyroiditis
- Extrinsic lesions (e.g. lymph nodes, goitre)
- Upper oesophageal web (e.g. Plummer–Vinson syndrome)
- Eosinophilic oesophagitis
- Radiotherapy
- Achalasia
- Upper oesophageal spasm (mimics angina)
- Rarities (some):
- Sjögren syndrome
- aortic aneurysm
- aberrant right subclavian artery
- lead poisoning
- cervical osteoarthritis (large osteophytes)
- other neurological causes
- other mechanical causes
Masquerades checklist
Depression
Drugs
Thyroid disorder
Is the patient trying to tell me something?
Yes.
Could be functional ?globus hystericus.
Key history
Analyse the nature of the symptom: difficulty in swallowing.
Its origin is either oropharyngeal or oesophageal.
A careful history includes a drug history and psychosocial factors.
Key examination
Focus on the patient’s general features
mouth, oropharynx, larynx
neck (esp. lymphadenopathy and thyroid)
any abnormal neurological features esp cranial nerve function and muscle weakness disorders
Key investigations
- FBE
- oesophageal manometry study (manometry)
- endoscopy ± barium swallow
- CXR.
The primary investigation in suspected pharyngeal dysphagia is a video barium swallow
while endoscopy is generally the first investigation in cases of suspected oesophageal dysphagia.
Diagnostic tips
Dysphagia must not be confused with the anxiety disorder globus hystericus (globus sensation),
- which is the sensation of a constant lump in the throat without swallowing difficulty.
- Treat with education and reassuring support.
Mechanical dysphagia represents carcinoma until proven otherwise:
- a short history of rapidly progressive dysphagia and
- significant weight loss
Be careful of a change in symptoms in the presence of longstanding reflux (consider stricture or cancer).
DxT:
dysphagia + chest discomfort + weight loss ± hiccoughs → oesophageal cancer
Red flag pointers for upper GIT endoscopy
- anaemia (new onset)
- dysphagia, esp. progressive dysphagea and for solids
- odynophagia (painful swallowing)
- haematemesis or melaena
- unexplained weight loss >10%
- vomiting
- older age >50 yrs
- chronic NSAID use
- severe frequent symptoms incl. hiccoughs, hoarseness
- family history of upper GIT or colorectal cancer
- short history of symptoms
- neurological symptoms and signs
